Seventeen-year-old Jacob Bates was found dead in a wooded area near Walton Dam two years ago.
His inquest this week heard he had been in and out of hospitals and secure units since taking an overdose when he was 14.
However, Peter Nieto, Derby and Derbyshire area coroner, recording a verdict of suicide today, said: “I cant find, on the balance of probability, that issues in Jacob’s treatment or care caused or contributed to his death.”
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He said Jacob’s death, on July 15, 2017, was caused by ‘1a, a ligature around his neck, and 1b, mental health issues and autism.’
The inquest heard evidence from Jacob’s parents, as well as a number of people involved in his care, including a psychiatrist, psychologist, social worker and care workers.
Summing up, Mr Nieto said: “He had difficulty interacting with other children and at times would become distressed.
“It was apparent he had marked difficulties at school, but they were not addressed.”
The inquest heard that in February 2014, he took a serious overdose.
From then, he was in a succession of hospitals and secure units, “for assessment, treatment and containment of his self-harm”, for more than two years, many of them far from his home.
In 2016, he moved to a residential unit in Stoke-on-Trent.
However, that November, the unit gave 28 days’ notice, stating his self harm and risk was too great for them to deal with.
Mr Nieto said: “The only placement deemed suitable was Emma House in Chesterfield – Jacob was delighted to be back in Chesterfield, close to his family.”
Emma House “provides 24-four hour support in a residential setting to young people aged 16 and above making the transition from dependent to independent living”.
However, Mr Nieto said: “Emma House was not known to have any specialism in mental health or autism. Emma House stated it could meet Jacob’s needs, but the agencies did not assess its competency that it could.”
“Two staff said they were employed with no formal experience or training, both were left in full charge of Jacob. Neither had been given significant training in advance.”
The inquest heard Jacob was increasingly allowed out unaccompanied and began to spend time at the home of his father, Glen Billyeald, on Old Hall Road, Brampton, before deciding he wanted to live there.
However, Mr Nieto said Emma House staff had concerns he would be relatively unsupervised at his father’s house, amid fears his father did not fully appreciate the level of Jacob’s needs.
Mr Nieto said: “There had been a number of self-harm incidents. Clearly the risk of self-harm was significant and continuing.”
However, ruling out any direct link to Jacob’s death, Mr Nieto said: “There were clear issues of concern to me relating to Jacob’s treatment and support.
“The lack of assessment and identification of his needs during his school attendance. It seems to me this was a lost opportunity.
“The long periods of time in out-of-area locations, some in inappropriate settings.
“The limited involvement by Jacob’s home area services, which should have been overseeing his care plan
“With the Stoke-on-Trent placement, it seems concerning that a organisation providing bespoke care to young people with high level of needs can give a short period of notice, knowing the difficulties that will ensue.”
“With the Emma House placement, I have not heard any evidence that any diligent checks were made on an unregulated provider, given Jacob’s needs. Emma House was clearly not suitable for Jacob. It was clearly an unsafe environment, on the evidence of care staff, for young people with high levels of needs.
“Regarding the placing with his father. Jacob was very strong-willed and detemined to spend time there. The agencies had no choice, all they could do was try to support him.”
However, he said he could not speculate whether had anything been done differently, the outcome for Jacob would have been different.
He said he planned to write to both the Secretary of State and Emma House to highlight his concerns.
Mr Nieto said: “It’s particularly concerning that there’s no statutory regularion for accommodation for young people aged 16-18. It is particularly concerning in general because young people at that age are likely to be vulnerable for a variety of reasons. I shall be writing to the Secretary of State.
“Although Emma House is unregulated, it seems to me it was under an obligation to have policies and practices in place with the experience and competence of staff.
Staff were hired without experience in working with young people, let along young people with high needs. I am going to write to Emma House. I want to know how it ensures its able to provide an effective and appropriate service. Depending on its reponse, I will then ponder if there are any further steps needed.”
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